Alcohol Misuse

Alcohol Misuse

Here you’ll find a comprehensive research review, created specifically for The Well. Analysing the contemporary evidence base on alcohol misuse, with up-to-date and academically reviewed information. Authored and academically reviewed by Professor John Toumbourou - Professor and Chair in Health Psychology at Deakin University; Honourary Senior Research Fellow at Murdoch Childrens Research Institute.

Last updated Jun 20, 2019

Alcohol Misuse

Although the specific nature of “alcohol misuse” is contentious, with various definitions proposed by various stakeholders, this resource is concerned specifically with alcohol misuse as it affects the broader community. “Alcohol misuse” is herein referring to use of alcohol which creates negative and preventable societal consequences, such as health costs, negatively impacting family relationships and parenting skills, harm to self or others, amongst other societal impacts which will be examined in greater detail below.

Strategic & Legislative Context


National

Liberalisation during the 1960’s

Alcohol liberalisation is recognised as a contributing factor to the increase in per capital alcohol consumption in Australia in the 1960s and the 1970s. Alcohol liberalisation refers to the loosening of government regulations, and this increase in the liberalisation of liquor licensing laws resulted in a rise in the number of liquor outlets in Australia and also extended opening hours of premises (Commonwealth of Australia, 2008). In addition, there was also an increase in the number of numbers of licences to sell take away alcohol (Hudson, 2011).

Public health strategies from the 1980’s such as publishing guidelines and taxing high alcohol beer

The steady decline in per capita alcohol consumption in the 1980’s is attributed to the implementation of Australian public health strategies relating to alcohol. In particular, the steady decline in per capita consumption of beer can be attributed to one specific Australian public health strategy that involved having lower taxes for low strength beers, as an incentive to drink these lower strength beers over standard beers (Nielson, 2006). The significant influence of this strategy is demonstrated by the decline in per capita consumption of beer since the implementation of this strategy, to the point that it is now at a level similar to that of the late 1950’s (Hudson, 2011).

The development and publication of the Australian Drinking Guidelines by the National Health and Medical Research Council (NHMRC) in 1986 is recognised as another Australian public health strategy that may have contributed to the decrease in alcohol consumption. These clear guidelines were developed to assist Australians to drink at levels that minimise the risk of harm by setting out a framework for decision making on the best available evidence about low risk patterns of alcohol consumption (Commonwealth of Australia, 2001). These drinking guidelines have advanced as new research and evidence has become available, with the latest guidelines having been issued in 2009 (ABS, 2002).

The development of the wine industry

Whilst the trends in per capita beer consumption have steadily declined over the past 50 years, per capita wine consumption has significantly increased during this same period of time (Hudson, 2011). The consumption of wine has increased almost fourfold since the late 1940’s (Hudson, 2011), and this can be attributed to the development of the wine industry, which was largely ignited by changes in consumer tastes towards wine and also the increase in availability in relatively cheap wine (Hudson, 2011). The expansion of the wine industry can also be attribute to the favourable tax regime for wine compared to beer and spirits. This has also encouraged consumption of cheap packaged wine and production of ‘alcopops’ wine based fruit drinks (Loxley, et al., 2004).

The real costs of wine have decreased since 1999 from $1 per glass to 90 cents per glass in 2008. This is contrasted to significant increases in real costs of beer and spirits over the same period making wine a very affordable choice. The overwhelming alcoholic drink of preference in Australia shifted considerably from 2001-2007, with bottled wine being highlighted as the beverage of preference in 2008 (Hudson, 2011).


Victorian

The need to prevent and reduce alcohol-related harms experienced at an individual and community level, is a priority expressed throughout the Victorian State Strategic Planning Framework [Victorian Department of Health Priorities 2007-2012, Victoria’s Alcohol Action Plan 2008-2013, Victorian Liberal Nationals Coalition Plan for Liquor Licensing]. All liquor licences, with the exception of limited licences and licences to manufacture alcohol, must have both a planning permit and a liquor licence. Practice Note 61, Licensed premises: Assessing cumulative impact (State Government Victoria, 2011) provides local governments with guidelines on how to assess the potential cumulative impacts of an application for a planning permit for a licensed premise on safety and amenity.

Liquor licences are issued, regulated and monitored by the Victorian Commission for Gaming and Liquor Regulation. The primary legislation under which these activities take place is the Liquor Control Reform Act 1998.


Local

Some local governments in Victoria have integrated planning policies into their planning schemes to provide guidance on measures to reduce the safety and amenity impacts of licensed premises on local communities. In addition, some local governments have developed alcohol management frameworks that describe best practice management and design strategies that focus on preventing and minimising alcohol-related harms, particularly in areas that have a high concentration of licensed premises that operate after hours, and those that sell alcohol for consumption off the premises.

Impacts and Outcomes


Health Costs of Alcohol Misuse

The abuse and misuse of alcohol is associated with a number of physical, cognitive and behavioural impacts which can have profound and long term impacts on individuals, families and the broader community. Alcohol is therefore second only to tobacco as a preventable cause of drug-related death and hospitalisation in Australia (AIHW, 2012). Alcohol is the causal factor in about 60 types of diseases and injuries, and a contributory cause in up to 200 others (AIHW, 2012).

As a result, alcohol abuse and misuse is increasingly being recognised as a serious health issue that needs to be addressed by all tiers of government and health care agencies. The consumption of alcohol is an intrinsic part of Australian culture, providing a range of social and economic benefits. Most Australians drink alcohol, generally for enjoyment, relaxation and sociability (NHMRC, 2009). However, recent scientific evidence presented in the Australian guidelines (NHMRC, 2009) suggests that any potential health benefits from consuming alcohol have been overestimated. Any benefits are mainly related to middle aged or older people and only occur with low-levels of alcohol intake of about half a standard drink per day, which is within the Australian guidelines (NHMRC, 2009).The Guidelines do not encourage people to take up drinking just to get health benefits.


Physical Health

The abuse and misuse of alcohol compromises the health and wellbeing of the individual drinker, people around the drinker and society at large. The volume, patterns and quality of alcohol consumed influences the incidence of chronic, infectious and acute conditions. Alcohol-attributable diseases include alcohol cirrhosis of the liver, cancer, epilepsy, ischaemic and cerebrovascular heart disease. Aside from the incidence of ill health, alcohol misuse contributes to other harms such as road injury, pedestrian road injury, assault, suicide and drowning.


Foetal Alcohol Spectrum Disorder

Foetal Alcohol Spectrum Disorders (FASD) is the leading preventable cause of non-genetic, developmental disability in Australia (FARE, 2013). It is caused by prenatal alcohol exposure, and can result in neuro-developmental disorders and birth defects, often associated with poor memory, impaired language and communication, poor impulse control, and mental, social and emotional delays.

The reasons for maternal consumption of alcohol during pregnancy are varied, and may include poverty, unemployment, abuse or family violence (Government of Canada, 2014). At present, strategies to prevent and address FASD in Australia are ad hoc and inconsistently funded. There are significant gaps in prevention, early intervention and management of FASD, with the result that health professionals are not equipped to screen for potential FASD and there are insufficient early intervention options for people with FASD.


Mental Health

People with mental health problems are at particular risk of experiencing problems relating to alcohol (Government of Australia, n.d.). There is evidence that alcohol increases the risk of highly prevalent mental health conditions such as depression and anxiety in some people, with around 37% of people who report problems with alcohol also having a co-occurring anxiety and or mood disorder (State Government of Victoria, 2012). The risk of having a mental illness is around four times higher for people who drink alcohol heavily than for people who don’t.


Harm to Others

Harm to others as a direct result of alcohol misuse include deaths, hospitalisations, child abuse and domestic violence. This harm may be experienced by co-workers, children, household members or strangers (WHO, 2014). Disease, death and injury related to alcohol consumption are linked to economic status. People experiencing lower socioeconomic status are at greater risk of alcohol-related health issues (WHO, 2014).


Crime and Safety

Alcohol abuse is also directly associated with a range of crime and safety issues such as road traffic accidents, falls, self-harm, prematurity and low birth weight, and violence (WHO, 2014). Impacts of binge drinking include public safety and amenity (violence, property damage, anti-social behaviour and perceptions of safety, which in turn lead to health issues such as road injuries, assaults, drowning, suicides, falls, fire and smoke injuries and sexually transmitted infections.


Economic Costs of Alcohol Misuse

Economic costs attributable to alcohol to the justice and health sectors of the broader community include health care and law enforcement. The economic impacts of alcohol abuse result from the impact on the ability of co-workers to carry out their tasks and the loss of productivity and absenteeism of those who drink (VicHealth, 2012).

Economic costs to the government include resources allocated to prevention and education campaigns, research, service provision, maintenance and law enforcement. The total social cost in relation to alcohol abuse during 2004 and 2005 cost $15318.2 million, with a further $1.1 billion attributable to the joint consumption of alcohol and illicit drugs. The avoidable costs of alcohol abuse in Australia and the potential benefits of effective policies to reduce the social costs of alcohol (Collins & Lapsley, 2008).

Within the workforce the tangible social cost equated to $3578.6 million between 2004 and 2005. The tangible social costs which are borne by the community as a result of alcohol and illicit drugs being consumed together was approximately $1057.8 million (Government of Australia, n.d.).

Alcohol related issues in public spaces and places such as anti-social behaviour, property damage, litter and noise can detract from real and perceived safety and amenity. This may discourage groups such as women, children and older people from visiting certain places or using public transport. This may affect people’s mental and physical health and wellbeing through reduced physical activity and social interaction.

Prevalence


General Consumption

Australia’s overall per capita consumption of alcohol is high by world standards, with the country currently ranked within the top 30 highest alcohol-consuming nations, out of a total of 180 countries (AIHW, 2012). Although overall levels of alcohol consumption and drinking patterns have not changed substantially over the past decade, there has been an increase in the number and proportion of people who drink at harmful levels.

In recent years, there has been an increase in the proportion of people, both males and females, who are drinking at risky levels (AIHW, 2012). Between 1995 and 2007/08, the proportion of men and women aged 18 or over who drank at ‘risky or high risk’ levels for their long-term health increased for men from 10% to 15%, and for women from 6% to 11%. In addition, the average number of days per week on which alcohol was consumed increased for men and women in almost all age groups, with larger increases for women than men.

In 2010, the following patterns of alcohol consumption were apparent (AIHW, 2012).

  • 81% of Australians aged 14 and over consumed alcohol;
  • 47% of Australians drank alcohol at least once a week with 35% drinking less often than weekly;
  • 1 in 5 Australians abstained from alcohol (including those who had never drunk alcohol and those who are ex drinkers).

The total consumption of alcohol in Australia has fluctuated over the past 50 years. From the early 1960’s onwards, apparent per capital consumption increased steadily, peaking at 13.1 litres of pure alcohol per person in 1974-75. Apparent consumption remained relatively steady for the next 5-10 years, then declined over the following decade, dropping to 9.8 litres per person in 1995-96. Apparent consumption then gradually increased to 10.6 litres in both 2006-07 and 2007-08, before declining over the past 3 years to 10.0 litres of pure alcohol per person in 2010-11.


Risky Consumption

One in five Australians (20.4%) drink at short-term risky/high-risk levels at least once a month. Put another way, this equates to more than 42 million occasions of binge drinking in Australia each year (Commonwealth of Australia, 2008).


Binge Drinking

In 2007 National Drug Strategy Household Survey, binge drinking was defined as consuming seven or more standard drinks. The term ‘binge drinking’ is popularly understood to mean someone going out to get drunk. However, the Australian Guidelines (NHMRC, 2009) do not define binge drinking because it means different things to different people, and is therefore difficult to define scientifically. Therefore, instead of the term ‘binge drinking’, the Guidelines refer to a single occasion of drinking.

Binge drinking i.e. short term consumption of alcohol at harmful levels is a prominent feature of the drinking culture in Australia. Binge drinking is defined as consuming seven or more standard drinks on any one day for males and consuming five or more standard drinking on any one day for females. This equates to drinking to the point of intoxication. One in five Australians i.e. 20.4% drink at short term risky/high levels at least once a month (Commonwealth of Australia, 2008).

Binge drinking is most prevalent among adults age 20-29, 24.9% of who do so on at least a monthly basis. Although Australian males are more likely to binge drink (17.1% of females compared with 23.6% of males), amongst teenagers, females are more likely than males to binge drink (28.3% of females compared to 24.5% of male teenagers).


Underage Consumption

Although the proportion of secondary school students aged 12-17 who drank alcohol in the previous week has decreased between 1984 and 2008 (from 30% to 17% for those aged 12-15 and from 50% to 38% for those aged 16-19), there was little change in the proportion of students aged 12-17 who consumed alcohol at levels that could lead to short-term harm (risky drinking) in the previous week between 1984 and 2008.

In 2010, 20% of people aged 14 or older reported drinking alcohol at levels that exceeded the 2009 guidelines and 39% of Australians aged 12 or older drank in a pattern that placed them at risk of an alcohol-related injury (AIHW, 2012).

Determinants


Population Health Planning for Alcohol Misuse

Health promotion and prevention activity relevant to alcohol and drug use can be conceptualised using a number of relevant frameworks. The Public Health Systems Model developed at the National Drug Research Institute (NDRI) (Lenton, 1996, cited by Loxley et al., 2004) in Figure 17 shows that prevention activity can be focused at a range of levels of increasing complexity, ranging from work with individuals to national and international approaches.

The Public Health Systems Model conceptualises the determinants of harmful alcohol and drug use on a continuum from macro (international mechanisms of action and contextual influences that impact large aggregate populations) to micro influences (individual drug use behaviour). Loxley et al, (2004) described the more distal influences at the international, national and state levels as social and structural determinants and more proximal influences within local communities, organisations, groups and at the individual level as risk and protective factors.

This model assists in mapping systems, pathways and strategies that connect among and between social and structural determinants and risk and protective factors and alcohol and drug use behaviours. It is clear that local community strategies will be most effective where supported by actions at higher levels.


Determinants and Risk Factors

Australia’s drinking cultures and consumption patterns are driven by a range of physical, social and economic factors associated with how available alcohol is within the community, the location of the venue in relation to sensitive uses and vulnerable groups, and the design and type of venue. Although there is no single factor that determines harmful drinking patterns, each of the determinants discussed below plays a significant role in determining the extent to which people may engage in harmful drinking behaviours.


Liquor outlet density

Outlet density is determined by the following:

  • The ratio of licensed premises per head of population e.g. 22 licences per 10,000 people (Donnelly et al., 2006)
  • The proportion of total licensed premises concentrated in a particular location.
  • The proportion of a particular type of liquor licence of all liquor licences.
  • Number of licensed premises within a specified catchment (State Government Victoria, 2011)

High densities of alcohol outlets are associated with harms including teenage drinking and drink driving (Gruenewald, 2011), medical harms, injury, crime and violence in the immediate surroundings and in adjoining neighbourhoods (Campbell et al., 2009).


Location in relation to sensitive users and vulnerable groups

Locations and groups particularly sensitive to alcohol-related health issues include young people, people experiencing social and economic disadvantage (WHO, 2014). This is particularly relevant in areas where there is a high concentration of packaged liquor licences (Livingston, 2012). Residential areas within 1.6km (Donnelly et al., 2006) of licensed premises, particularly those that operate beyond normal trading hours, may be affected by a range of alcohol-related issues including noise from people, cars and the venue; property damage; vandalism; anti-social behaviour; crimes and assaults.


Price

The price of alcohol relative to earnings will determine how affordable, and therefore accessible alcohol is to purchase and consume. Price is an important factor influencing levels of consumption and alcohol-related harm (WHO, 2011) at an individual and community level (Leicester, 2011). Young people and heavy drinkers are particularly sensitive to the price of alcohol (WHO, 2011).

Higher density increases potential for competition and lower prices, both of which are associated with excessive alcohol consumption (Livingston et al., 2007). This is particularly relevant for packaged liquor licences (licensed supermarkets, boutique bottle shops or ‘big box’ bottle shops) in high density areas (Bowley, 2011) located in disadvantaged communities (Livingston, 2012). However there is no evidence that price can be influenced or changed at the regional or local level.


Trading Hours

Trading hours determine when and for how long alcohol is available for purchase and consumption in licensed premises and private homes. There is a direct and positive correlation between longer trading hours (between midnight and 3am over the weekend) and anti-social behaviour, violence, fears of safety, road traffic casualties and property damage (Briscoe & Donnelly, 2001) (Wicki & Gmel, 2011). In addition, later closing times shift alcohol-related issues to later times of the night (WHO, 2011) which has implications on the demand for emergency services such as police and ambulance.


Patron Capacity

The maximum permissible number of patrons in a venue determines how many people can be accommodated, both within a venue and within a defined physical catchment that has a number of licensed premises e.g. an entertainment precinct. Venues such as restaurants, bars, nightclubs and pubs with patron capacities above 200 are generally considered to be the most risky, and are associated with issues such as crowding within and outside the venue, anti-social behaviour, parking and traffic congestion, assaults and excessive demands on public transport.


Venue type, design and mix

Venues such as bars and nightclubs where the consumption of alcohol is the primary activity are associated with the most harm. Venues associated with poor management styles and poorly designed internal spaces may decrease the real and perceived safety of patrons. A poor mix of venue types may reduce choice and can contribute to homogenous drinking environments that are associated with particular patron profiles.


Design of the public realm

Factors such as footpath design, location and capacity of car parking areas, street lighting, maintenance, wayfinding signage and the presence of enclosed and poorly monitored spaces can reduce the real and perceived safety of an area. On the other hand, factors such as adequate public transport, good natural surveillance and appropriately located doors and windows can enhance the real and perceived safety and comfort of both patrons and the broader community.


Drinking cultures

Australia’s varied drinking cultures date back to the initial British colonisation. Contemporary drinking cultures continue to be defined by specific social norms and values that affect the extent to which the consumption of alcohol will compromise health and wellbeing. It has been recognised that too many Australians are partaking in ‘drunken’ cultures rather than drinking cultures, and that many of the dangers of alcohol for those who drink and those around the drinker, are misunderstood, tolerated or ignored (Commonwealth of Australia, 2006). This is particularly apparent with regards the causes and effects of drinking to intoxication. The increase in the incidence of binge drinking amongst young people, particularly women, has been attributed to Australian tolerance toward youth alcohol use (Commonwealth of Australia, 2006).

Although the majority of drinking amongst Australia’s workforce takes place after hours and on days off, some does occur during the working day. Harmful use of alcohol, both during and after working hours, is associated with adverse impacts such as workplace accidents and injuries, workplace fatalities, reduced productivity, poor work relationships, and increased absenteeism and presenteeism (decreased on-the-job performance) (VicHealth, 2012). Workplaces are powerful settings for both establishing and harmful alcohol consumption cultures and supporting the promotion of health to a large audience. They are also significant determinants of the physical, mental, economic and social wellbeing of employees (VicHealth, 2012), all of which influence the levels at which people may consume alcohol.

The increase of liquor sales during December and April (to a lesser extent) (Richardson, 2012) indicate that there is a strong seasonal pattern to alcohol consumption. This pattern is also reflected in the increase in domestic violence in the months of December and January, and other public holidays such as Melbourne Cup Day.

Most of domestically consumed alcohol is consumed directly by households, presumably in private homes. However a large share is also consumed as part of a purchase of food and beverage services at venues such as bars, taverns and restaurants (Richardson, 2012).


Parental Influence

Most adults are likely to express concerns relating to consumption of alcohol by young people in general, and binge drinking in particular. Nevertheless, in many instances young people obtain their alcohol from adults and a large proportion of young people obtain alcohol from their parents (Australian Government, 2004). Some of these adults, including parents, may be unaware of the dangers associated with underage drinking or the legislative restrictions on supplying alcohol to young people under 18. In other instances, often within migrant communities where attitudes to alcohol consumption are conservative, parents may be unaware that their children are consuming alcohol without adequate adult supervision or consent.

Adolescents who are poorly monitored begin consuming alcohol at a younger age, tend to drink more, and are more likely to develop problematic drinking patterns and effective parental monitoring may reduce the effect of peers (Australian Government, 2004).

Some Australian parents may underestimate their consumption patterns of their children, and may be more concerned about illicit drug use than alcohol use. Others may feel pressured to accept alcohol use by adolescents as normal. Young people’s attitudes towards and patterns of alcohol consumption may be modelled on the norms, values, attitudes and goals of adults, particularly those closest to them such as their parents (Australian Government, 2004). As a result, the regular exposure of harmful drinking patterns amongst adults may normalise binge drinking behaviours by children. The NHMRC (2009) guidelines recommend that adolescents do not use alcohol prior to age 18. An increasingly important goal is encouraging children to avoid alcohol use.


Alcohol Marketing

Factors such as advertising, marketing and location of the licensed venue will determine how exposed individuals are to the presence of alcohol in their neighbourhood, and therefore how available alcohol is perceived to be. High exposure to alcohol can influence social and cultural attitudes to consumption of alcohol by normalising their presence in places where people conduct their day to day activities.

Alcohol advertising and promotion increases the likelihood that adolescents will start to use alcohol and to drink more if they are already using alcohol (Australian Government, 2009). Exposure to venues is determined by the extent to which licensed premises are accessible and visible from important locations such as gateways, destinations and attractions.

Footpath trading permits extend the physical area of a licensed venue within which alcohol may be consumed.

Vulnerable Population Groups


Children and Young People

Drinking contributes to the three leading causes of death among adolescents, namely unintentional injuries, homicide and suicide, and risk-taking behaviour, unsafe sex, sexual coercion and alcohol overdose (Commonwealth of Australia, 2008).

Under aged Drinking

One of the five ethical principles and goals embedded in The European Charter on Alcohol is that all children and adolescents have the right to grow up in an environment protected from the negative consequences of alcohol consumption and, to the extent possible, from the promotion of alcoholic beverages (WHO, 2006).

Secondary Supply

Secondary supply refers to the provision of alcohol products to young people under the age of 18 by a third party. In Victoria regulations in the Liquor Control Reform Act 1998 make it illegal to supply alcohol to a person under 18 in a private residence without the consent of the parent or guardian. This includes parents providing alcohol to their children or their children’s friends, as well as other people such as siblings and friends over the age of 18 supplying alcohol to people under the age of 18.

Preloading

Some slight increases in per capita alcohol consumption in Australia over time may be attributable to the emergence of new patterns of alcohol consumption among youth and young adults, such as preloading. Preloading, which is also known as ‘pre-drinking’, ‘pre-partying’ or home drinking, is when an individual consumes alcohol before going out to a licensed venue such as a pub, bar or club (Turning Point, 2012). Recent research reveals that three quarters of Victorian youth are now preloading on alcohol (WHO, 2011). The main reason behind the emergence of this trend among young Australians is to save money, with individuals reporting that it is much cheaper to buy alcohol from bottle shops than from clubs, pubs and bars. Preloading is often heavy drinking, to the point where many people are getting drunk before they go out. To further demonstrate this, research has highlighted that a strong relationship exists between pre-drinking and extreme binging, which is the consumption of 11 or more standard drinks in one session at least once a month over the past year. As a result of the associations and trends, preloading has been shown to considerably increase the risk of long term alcohol related harm (Donnelly et al., 2006).


Maternal Drinking

Pregnant women – one in five women continues to consume alcohol while pregnant after knowledge of pregnancy, despite national alcohol guidelines which state that it is best to avoid alcohol altogether during pregnancy. (FARE, 2012).


Aboriginal and Torres Strait Islanders

Aboriginal and Torres Strait Islanders – Indigenous Australians may be up to six times more likely to drink at high-risk levels than non-Indigenous people (Commonwealth of Australia, 2008).

Alcohol consumption, together with nutrition, smoking and the use of other drugs and substances, is a key health risk factor contributing to the greater burden of ill health experienced by Aboriginal and Torres Strait Islander people. Although some studies indicate that Indigenous Australians are less likely than other Australians to drink alcohol, those who do so are more likely to consume it at hazardous levels. The National Health Survey of Aboriginal and Torres Strait Islanders in 2004-05 showed that 63% of all respondents consumed alcohol in the week prior to the interview, 16% of which had consumed alcohol at a high risk level. Indigenous males (109%) are more likely to consume alcohol at high risk levels than Indigenous females (14%) (AIHW).


Other Vulnerable Groups

  • People aged 18-24 (31% of whom consume alcohol in risky quantities on a weekly basis)
  • People living in rural and remote areas
  • People employed in the agriculture, retail, hospitality, manufacturing, construction and financial services industries (VicHealth, 2012).

Interventions


Prevention Model

There are a range of influences within local communities that impact alcohol and drug use behaviour, and that can therefore be targeted in local efforts to reduce alcohol and drug problems. Figure 17.1 below provides a summary from Loxley, et al., (2004) of areas of focus that can be tackled to reduce drug related harm. As relevant to community-level prevention strategies, Figure 17.1 suggests that a carefully coordinated mix of prevention activity (investments), rather than any single activity has the greatest chance of leading to reductions of community problems. The range of possible strategies suggests the importance of tailoring the mix of investments to the specific and distinct needs of particular communities.

Figure: A summary of recommended prevention strategies to reduce drug related harm (modified from Loxley et al, 2004 as cited above)

Universal strategies

The box on the left of Figure lists a range of universal prevention strategies that have demonstrated evidence that they can be implemented to reduce problems associated with legal drugs such as alcohol and tobacco.

  • Some of these such as Taxation & Price have an important impact, but require national action and are difficult to directly influence at the regional and local levels.
  • Regulation involves a broad class of strategies enacted by state and local government that include laws that influence where and to whom alcohol and tobacco can be sold and used.
  • Enforcement of regulations typically includes strategies involving a local community component and may include community police and municipal officers working closely with state authorities to provide education and enact penalties for rule violations.
  • Also included in this list is Education that includes broad-based strategies such as quality school education and school organisational improvement together with more specific drug education strategies.
  • Parent support involves a range of strategies aiming to maximise family effectiveness that can be influenced at a community-level.
  • Community improvement includes a broad range of strategies aimed at enhancing community amenity and access to services while attempting to reduce norms that are favourable to unhealthy behaviours and social marginalisation and economic disadvantage.

Prevention strategies

  • Targeted early age prevention includes a range of strategies directed at vulnerable mothers and families providing maternal and family support to ensure healthy child development through infancy, pre-primary and primary school.
  • Targeted adult interventions such as treatment with involvement of family members and harm reduction strategies, delivering services to families or to young people in the family formation age group also provide opportunities for targeting early age prevention strategies.
  • Where they are well coordinated at the community level, universal and targeted strategies work in conjunction to improve community systems.
  • The circles to the right of the Figure depict the integrated relationship between adolescent drug use and the patterns of drug use modelled more broadly by adults, emphasising the importance of addressing drug use in different age groups.

Population-level benefits

The box to the right of the Figure identifies that there are potentially multiple benefits that can flow from a well-coordinated set of community prevention strategies. This potential for multiple benefits suggests the advantage of integrating community drug prevention investments with different sectors including those concerned with social improvement, mental health promotion and crime prevention.


Good practice principles

Good practice principles that can be identified from the evaluated strategies detailed in later sections include the following:

  • Reductions in alcohol-related harm at a community level are often achieved through local enforcement and support for effective national and state policies and programs. For example where state policies prohibit the supply of alcohol to intoxicated patrons or underage youth, effective local actions can be implemented to enforce these policies.
  • Effective programs are guided by logical links between the intervention activities and the community processes that can result in harms.
  • Activities often focus on mobilising community support before attempting to change policies, regulations or enforcement practices.
  • Data systems are a potentially important component in the evaluated interventions and assess a range of factors including: influencing factors, policy and program impacts on influencing factors, markets, behaviours and harms to be addressed. In most cases specialist data and indicators (underage confederate alcohol purchasing, organising hospital data on alcohol harms) needs to be developed within communities.
  • Effective community actions require partnerships that: encourage community involvement and ownership; provide training and access to technical expertise through links to university teams and other experts and; build capacity in key community institutions that are relevant to prevention such as schools, the police and local retailers.

Lenses for Interventions

Across the region there are diverse geographic areas that are important to understand and consider for health promotion planning regarding alcohol. The following four areas or lenses are described below. The implications for interventions in later sections relevant to distinct risks associated with alcohol-related harms:

  1. Region-wide issues that affect the whole population
  2. Areas projected to house large populations of children
  3. Disadvantaged communities
  4. Entertainment precincts and alcohol sales areas

Region-wide issues

Region-wide issues that affect the whole population in relation to alcohol include:

  • Regular use of alcohol at amounts that exceed the national guideline recommending no more than two standard alcoholic drinks per day (fourteen drinks per week) increases the risk of long-term health problems (NHMRC, 2009). Regular drinking alcohol in amounts that exceed the recommended guidelines contributes to over 61 disease diagnoses. In 2010 of the Australian population aged 14 or older 20.1% reported average alcohol use that exceeded guidelines to reduce long-term risks (AIHW, 2011).
  • Occasions of alcohol use that exceed the national guideline recommending no more than four alcoholic drinks in a single session increases the risk of short-term harm (NHMRC, 2009). Short-term harms from excessive amounts of alcohol use include: injuries; accidents; violence; social problems; and risky sex. In 2010 39.7% of Australians aged 14 years or older drank, at least once in the last 12 months, in a pattern that increased their risk of short-term harms (AIHW, 2011).
  • There are opportunities for regional and local interventions to prevent harms by reducing alcohol use to recommended levels through: social marketing; community mobilisation; health education; enforcement of liquor licensing regulations; brief interventions; and treatment interventions (Loxley, et al., 2004).

Areas projected to house large populations of children

Areas projected to house large populations of children have the challenge of reducing the influence of alcohol for parents, children and adolescents. These challenges include:

  • Pregnant and breastfeeding mothers – one in five women continues to consume alcohol while pregnant after knowledge of pregnancy, or while breastfeeding despite national alcohol guidelines which state that it is best to avoid alcohol altogether during pregnancy and breastfeeding (FARE, 2012).
  • Children and adolescents – Although the national alcohol guidelines recommend no alcohol use until adolescents turn 18, the majority of secondary school adolescents drink alcohol. Early age alcohol use leads to heavy use during adolescence which predicts adverse physiological and neurological changes and life-long patterns of harmful alcohol use. Drinking contributes to the three leading causes of death among adolescents, namely unintentional injuries, homicide and suicide, and risk-taking behaviour, unsafe sex, sexual coercion and alcohol overdose (NHMRC, 2009).
  • There are opportunities for regional and local interventions to prevent and reduce these problems through: social marketing, community mobilisation; health education; and enforcement of underage drinking liquor licensing regulations.

Disadvantaged communities

Disadvantaged communities often have more entrenched alcohol problems and require a greater focus on early intervention and treatment responses to reduce harmful alcohol use and interventions to protect against inter-generational transmission by integrating with early years work.

  • Heavy alcohol and drug use and harmful practices such as alcohol use and tobacco smoking while pregnant or breastfeeding are more common for those with lower levels of education.
  • Alcohol and drug problems are more common amongst clients on unemployment benefits and not in the workforce and receiving income support (e.g., sickness, disability benefits).
  • Aboriginal and Torres Strait Islanders – Indigenous Australians have lower overall rates of alcohol use, but where using alcohol may be up to six times more likely to drink at high-risk levels than non-Indigenous people (Commonwealth of Australia, 2008).
  • Heavy alcohol use is more common for “working class” people employed in the agriculture, retail, hospitality, manufacturing, construction industries and for some professions such as the financial services industries (VicHealth, 2012).

Entertainment precincts and alcohol sales areas

Entertainment precincts and alcohol sales areas often require a special focus of attention to encourage safe venues, reduce situational harms and to enforce liquor license regulations.

  • The density of alcohol sales outlets and their marketing and sales practices influence the levels of alcohol use and harm within their surrounding communities.
  • People aged 18-24 (31% of whom consume alcohol in risk y quantities on a weekly basis) are more likely to attend and experience harms at alcohol entertainment venues.
  • Males (48% of males drink alcohol in quantities that placed them at risk from a single occasion of drinking compared to 29% of females) are more likely to be perpetrators and victims of alcohol-related violence, while females are more likely to experience alcohol-related sexual abuse. These problems are more likely to occur during entertainment nights and on weekends and are influenced by drinking venues.

Categories of Intervention

Interventions devised to prevent and manage alcohol-related harms are based on the principles of demand reduction, supply reduction and harm reduction. Seven categories of interventions have been defined, as follows (Commonwealth of Australia, 2008).

  1. Regulating physical availability
  2. Taxation and pricing
  3. Drink-driving countermeasures
  4. Treatment and early intervention
  5. Altering the drinking context
  6. Regulating promotion
  7. Education and persuasion

Addressing the social determinants

We define social determinants in this document as influences that impact large national and state populations. These may include the national and state economy, and government policies and investments in areas that include employment, social security, health, human services, and education. As relevant to alcohol, national policies such as taxation and price controls have solid evidence for reducing alcohol related harm. State policies including alcohol industry regulation also have evidence for effectiveness. Implementing these interventions will rely on federal and state political will (Vos). Social determinants can be responded to in regional and local planning, and this is particularly useful in contexts where regional health planning is supported by national and state policies.

Addressing modifiable risk/protective factors at the regional and local levels

Supply reduction, demand reduction, harm reduction (Australia’s National Drug Strategy) aim is to prevent the uptake and minimise the harmful effects of drug use in Australian society’. This is a harm minimisation approach, that also adopts the ‘prevention paradox’ which suggests that more harm may be prevented through universal interventions that focus on the majority who are less seriously involved in harmful alcohol and drug use, rather than through interventions that only target the smaller proportion of high-risk users (Commonwealth of Australia, 2001).

Examples of Interventions

The sections below summarise the published evaluations of community interventions that have demonstrated population reductions in alcohol and drug related harm and related influences. Research was identified from previous systematic literature reviews (Loxley et al., 2004; Toumbourou et al., 2007; Toumbourou et al., 2013). In what follows the evidence that these projects had a positive impact is summarised together with the community processes these interventions utilised to achieve positive impacts.

The sections presented here outline policies and interventions that can be implemented at the regional and local community levels to address the following four planning issues:

  • Region-wide issues that affect the whole population
  • Areas projected to house large populations of children
  • Disadvantaged communities
  • Entertainment precincts and alcohol sales areas.

The following symbols are used to indicate the current level-of-evidence for health promotion strategy impacts on alcohol and drug use (Loxley et al, 2004 cited above):

★ Evidence for implementation

★★ Evidence for outcome efficacy

★★★ Evidence for effective dissemination


Region-wide interventions to reduce risky alcohol use patterns that affect the whole population

The table below summarises interventions and the evidence for regional and local interventions to prevent harms and reduce alcohol use to recommended levels across the whole regional population. The interventions described in this section include: community mobilisation; health education and social marketing; development and enforcement of alcohol laws and liquor licensing regulations; brief interventions; police and court actions to motivate alcohol treatment entry; treatment; and harm reduction (road, transport and community safety) interventions.

To be effective alcohol health promotion, treatment and harm-reduction interventions need to be well planned as a whole-system and monitored using data examining the: quality of implementation; impacts on targeted processes such as attitudes and alcohol supply practices; and outcomes on alcohol use behaviours.

Table: Region-wide interventions aimed at reducing risky alcohol use patterns that affect the whole population (Loxley, et al., 2004) (Toumbourou, et al., 2007).

Strategy goal

Mix of interventions

Potential regional action to enhance capacity and resources

Community mobilisation and organisation

Local alcohol health promotion coalitions to coordinate social marketing and to develop alcohol behaviour change strategies with health and social services.

Coalition support to develop alcohol management plans with alcohol sales organisations, police, and alcohol regulators to reduce harmful marketing, sales and operating practices.

Forums, and agreements to establish, coordinate and monitor: social marketing; alcohol behaviour change strategies; and alcohol management plans. ★

Health education and social marketing

Using health behaviour change theories to develop and communicate information on the national alcohol guidelines and to use monitoring to revise communications to ensure impacts and behavioural outcomes.

Funding the development and testing of information and communications, the collection of monitoring data to revise communications to ensure impacts, and scaling up to achieve population level behavioural outcomes. ★

Development and enforcement of alcohol laws and liquor licensing regulations

Monitoring and reducing sources of supply of alcohol to underage and intoxicated patrons. Encouraging the development and enforcement of alcohol laws (e.g., secondary supply, alcohol in public spaces). Linking data on alcohol supply to police and health emergency databases.

Alcohol sales and supply monitoring studies, communication and advocacy to develop and enforce alcohol laws and liquor licensing regulations. ★★

Brief interventions

Motivating and facilitating behaviour change to reduce risky drinking by delivering effective brief-counselling, health-information interventions within primary care settings using face-to-face and interactive computer administered programs.

Establishing service agreements with primary care providers. Funding: training in effective strategies; pilot programs; monitoring to ensure implementation; and evaluation of behaviour change targets. ★★

Police and court actions to motivate alcohol treatment entry

Increasing police warnings and court diversion for alcohol offenders to increase their motivation to enter treatment programs.

Liaising to establish agreements and training programs with police and courts. ★

Treatment interventions

Reducing the risky drinking of people with alcohol use disorders and problems by increasing the delivery of treatment interventions by increasing motivation (using social marketing, brief interventions and court mandated intervention) to access treatment and by ensuring treatment places using effective: counselling; medically-aided; residential; and self-help strategies.

Auditing the availability of treatment places; establishing region-wide agreements with service providers. Funding: training in effective strategies; pilot programs; monitoring to ensure implementation; and evaluation of behaviour change targets. ★★

Harm reduction: road, transport and community safety

Reducing alcohol-related harm through: effective drink-drive prevention; pedestrian safety; injury prevention; and community crime prevention.

Encouraging community crime and injury prevention forums. Encouraging region-wide coordination of strategies. ★★

The following symbols are used to indicate the current level-of-evidence for health promotion strategy impacts on alcohol and drug use (Loxley et al, 2004 cited above):

★ Evidence for implementation.

★★ Evidence for outcome efficacy

★★★ Evidence for effective dissemination.

In addition to the above regionally implemented interventions advocacy efforts are also warranted to encourage national and state policies that can effectively reduce local and regional levels of alcohol use and harm. National policies should be encouraged to increase: the taxation; and price of alcohol. National and state policies should aim to restrict freedoms to: market; sell; and supply alcohol.


Interventions for parents, children and adolescents in areas projected to house large populations of children

The table below summarises strategies for preventing early age and frequent adolescent alcohol use in areas where the projected population profile is expected to include large numbers of families with children. The Table describes the level of evidence for actions that can be implemented at the regional and local community levels to modify family, school and community environments. To be effective intervention plans can be tailored to address youth reports of risk and protective factors within their family, school and community environments and monitored for their adherence to effective intervention processes using the Communities That Care youth survey.

Table: Evidence for intervention strategies aimed at reducing the rate of child and adolescent alcohol and drug use (Loxley, et al., 2004) (Toumbourou, et al., 2007) (Toumbourou, Olsson, Rowland, Renati, & Hallam, 2013)

Strategy goal

Mix of interventions

Potential regional action to enhance capacity and resources

Healthy family environments for children and young people

Parent education for families with infants and children: Activities to improve parent effectiveness.

Community and school education to increase parent and adult awareness of current alcohol policies and laws.

Offering training in effective parent education models (e.g. Triple P). ★★

Social marketing communication and advocacy to change parent and adult practices (e.g., Smart Generation). ★

Healthy school environments

School organisation programs: Activities that ensure schools have expertise in mental health promotion and family/ community connections and effective alcohol and drug education and policies.

Fund school mental health promotion professional training (e.g., Gatehouse, Kids matters, Mindmatters). ★★★

Fund activities that build school and family partnerships in each school (e.g., Resilient Families). ★★

Social marketing and community mobilisation

Regional and local strategies to convey key messages across the population and within targeted groups to encourage of national youth alcohol guidelines and reduction of alcohol supply to underage youth.

Fund and coordinate professional and community training in strategies to reduce underage drinking (e.g. Communities That Care). ★

Community opportunities for alcohol-free sport, recreation and entertainment

Policies and programs that encourage healthy opportunities and that discourage unhealthy practices.

Encouraging adoption of the Good Sports program. ★★

Encouraging alcohol-free entertainment and recreation events Ie.g., Freeza). ★

Community enforcement of state and national policies

Monitoring and enforcing regulations to reduce sources of supply of alcohol to underage youth.

Local monitoring surveys, communication and advocacy to reduce supply sources. ★★

The following symbols are used to indicate the current level-of-evidence for health promotion strategy impacts on alcohol and drug use (Loxley et al, 2004 cited above):

★ Evidence for implementation.

★★ Evidence for outcome efficacy

★★★ Evidence for effective dissemination.


Intervening within disadvantaged communities

The table below summarises interventions for reducing heavy and harmful alcohol and drug use within in communities that house high concentrations of socioeconomically disadvantaged populations. Interventions in these contexts seek to reduce alcohol as a cause of disadvantage by integrating across treatment, employment and housing support and by protecting children from inter-generational transfer of alcohol and drug problems. Higher levels of disadvantaged are associated in Australia with higher fertility and childbirth at younger ages, hence effective child and adolescent interventions can reduce inter-generational problems.

Late-stage crisis interventions are common in these communities but have not been effective at reducing growing social differentials and problems such as child neglect. The Table describes preventative actions that can be taken at the regional and local community levels and have evidence for effectiveness. Monitoring data such as the Australian Early Development Index (AEDI) and the Communities That Care primary school student self-report surveys can be used to plan and monitor regional progress in encouraging healthy environments and reducing the burden of alcohol-related problems for children in disadvantaged communities.

Table: Health promotion strategies aimed at reducing harmful alcohol and drug use in disadvantaged communities (Loxley, et al., 2004) (Toumbourou, et al., 2007) (Toumbourou, Olsson, Rowland, Renati, & Hallam, 2013) (Toumbourou, et al., 2007)

Strategy goal

Mix of interventions

Potential regional action to enhance capacity and resources

Reducing adolescent alcohol and drug use to reduce parental alcohol and drug use

Child and adolescent interventions to reduce early age sexual activity, pregnancy and substance use (see above table).

Targeted community and school programs to increase parent and adult awareness and adoption of current alcohol policies and laws.

Investing in child and adolescent interventions (e.g., Gatehouse, Communities That Care). ★★

Court mandated programs to change harmful parent and adult practices. ▼

Supporting vulnerable mothers and families

Family home visiting, integrating parent education into alcohol treatment services to encourage recovery and reduce foetal alcohol problems and child neglect and abuse.

Training events to build capacity in family home visiting services (e.g., ARACY). ★★

integrating parent education into alcohol treatment services (e.g., PUP). ★

Healthy pre-school and early school environments

Increasing opportunities for high quality pre-school and early primary school participation for students from disadvantaged backgrounds.

Training events in effective programs (e.g., Tuning into Kids, Good Behaviour Game, FastTrack, Seattle Social Development Project). ★★

Region-wide and youth focussed intervention

See interventions in previous tables.

See interventions in previous tables. ★

The following symbols are used to indicate the current level-of-evidence for health promotion strategy impacts on alcohol and drug use (Loxley et al, 2004 cited above):

▼ Warrants evaluation research

★ Evidence for implementation

★★ Evidence for outcome efficacy

★★★ Evidence for effective dissemination


Interventions within entertainment and alcohol sales precincts

The table below summarises interventions and their evidence for managing alcohol within entertainment and alcohol sales precincts. Management intervention often begin by establishing local agreements to: eliminate discounting and limit operating hours (e.g., packaged outlets close at 10pm, in-house bar sales at 2am) and increase enforcement of regulations. To be effective alcohol management plans require monitoring data using strategies such as: alcohol test purchase attempts with decoy patrons that appear underage; observation or measurement of intoxicated patrons; record linkage to examine sources of alcohol supply for alcohol-affected attendees in police and health emergency files; using data on harmful alcohol supply to prevent injury and crime and enforce liquor regulations.

Table: Intervention strategies aimed at managing alcohol within entertainment and alcohol sales precincts (Loxley, et al., 2004) (Toumbourou, et al., 2007) (Toumbourou, Olsson, Rowland, Renati, & Hallam, 2013) (Toumbourou, et al., 2007)

Strategy goal

Mix of interventions

Potential regional action to enhance capacity and resources

Community mobilisation and organisation

Local alcohol management plans with alcohol sales organisations, police, and alcohol regulators to reduce harmful marketing, sales and operating practices.

Forums, and agreements to establish and monitor local alcohol management plans. ★

Community enforcement of state and national policies

Monitoring and reducing sources of supply of alcohol to underage and intoxicated patrons. Linking data on alcohol supply to police and health emergency databases.

Alcohol sales monitoring surveys, communication and advocacy to enforce liquor licensing regulations. ★★

Road, transport and community safety

Drink-drive prevention, pedestrian safety, injury prevention, community crime prevention.

Encouraging community crime and injury prevention forums and strategies. ★★

Police and court actions to control offenders

Police warning and court diversion into treatment programs for alcohol offenders.

Police and court training programs. ★

The following symbols are used to indicate the current level-of-evidence for health promotion strategy impacts on alcohol and drug use (Loxley et al, 2004 cited above):

★ Evidence for implementation.

★★ Evidence for outcome efficacy

★★★ Evidence for effective dissemination.

References

Alcohol Misuse References

Apr 13, 2018

Alcohol Misuse References

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